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Dr. Mohamed AlshekhaniProfessor in Medicine

MBChB-CABM-FRCP-EBGH 2016

Introduction:• Common, • It is the most frequently detected anomaly on colonoscopy.• The disease can be asymptomatic, noted on colonoscopy, or it can

present with bleeding ( diverticular bleeding) or inflammation (diverticulitis).

• The overall rates of complications of bleeding are quite low, most cases will resolve spontaneously.

• Diverticulitis can be associated with infection, sepsis, perforation.• Often antibiotics are used & surgery may be warranted in certain

cases.

EPIDEMIOLOGY:• Overall prevalence increases with age,50% if = or >60 ys.,70% by 80.• West have higher prevalence than Africa / Asia<0.5% ?Fiber in diet.• Low fiber causes longer stool transit time resulted in the DD from

increased wall pressure.• Hospitalization for diverticulitis is more common in white women. • Most are 40 - 80 years.• In West, most diverticular disease is in the sigmoid colon,but in

Asia, right-sided diverticular disease is the predominant.• The risk of being hospitalized for diverticulitis is 3 times higher than

that associated with diverticular bleeding.• The truelife-time risk of diverticulitis is <1-5%, with • Diverticulitis is >in patients 18 -80 years than bleeding&>in women.• < 50 years, diverticulitis occurs more often in men than in women.

PATHOPHYSIOLOGY:• The exact pathological mechanisms unknown.• Recent throries stress on genetics, diet, motility, microbiome,

inflammation> food/or stool lodging in diverticula, causing trauma, ischemia, necrosis& focal perforation .

• One of the leading theories is increased pressure in areas of weakened walls.

• With age, there is degeneration of the mucosal wall &increase in the colonic pressure that bulges in areas of insertion of the vasa recta

PATHOPHYSIOLOGY:Gentics• Play a significant role. • Increase in twins.• Heritability effect is 40% &nonshared environmental effect 60%.• Specific genes, TNFSF15 SNP rs 7848647 implicated in the

development &complications.

PATHOPHYSIOLOGY:Motility• Neural degradation that occurs with age in the myenteric plexus &

myenteric glial cells&interstitial cells of cajal results in uncoordinated contractions& subsequent increased pressure.

PATHOPHYSIOLOGY:Microbiome• Changes in the microbiome implicated.• Long-standing stasis of feces may result in a chronic microbiome

dysbiosis&result in a chronic inflammatory state.• There was an increase in the Firmicutes/Bacteroidetes ratios

&overall levels of Proteobacteria.

PATHOPHYSIOLOGY:Inflammation• Associated with symptomatic DD & complications.• Increase in microscopic inflammation from chronic lymphocytic

infiltration&active neutrophilic & enhanced expression of TNF• Ongoing histological inflammation is associated with an increased

risk of recurrent diverticulitis.• Segmental colitis associated with diverticulosis (SCAD), associated

with the macroscopic finding of chronic inflammation in diverticula on colonoscopy.

Terminology:• Diverticulosis: Presence of diverticula• DD: Clinically significant& symptomatic diverticulosis.• Acute diverticulitis: Active inflammation (isolated or

recurrent ,uncomplicated or complicated).• Asymptomatic uncomplicated diverticular disease: diverticulosis

without any symptoms or complications most often noted incidentally on colonoscopy or on radiological imaging.

• Symptomatic uncomplicated diverticular disease (SUDD): Symptoms of diverticulosis without any visible inflammation or diverticulitis even previously with episodes of abd pain without evidence of inflammation, pain will come &go but can be constant, may be relived with flatus or BMs,with abd pain, bloating,C,D.

• Recurrent symptomatic uncomplicated diverticular disease: R-SUDD• Segmental colitis associated with diverticulosis(SCAD): chronic form

mimic IBD with evidence of macroscopic inflam on colonoscopy.

RFs:• Fiber does not prevent diverticulosis, but may have a role in

preventing diverticular disease• Veg diet reduced the risk of hospitalization & death from DD.• Nuts, corn,seeds were not associated with any increase in

diverticulitis or diverticular bleeding.• Diets high in red meat & fat.• NSAIDs, corticosteroids, opiates associated with a risk of both

diverticulitis&diverticular bleeding,• Obesity &smoking is associated with a risk of diverticulitis • Smokers have an increased risk as well (odds• Vege diets& increased physical activity protective of DD.• Medications protective are CCBc/statins. • Higher vitamin D reduce the risk of hospitalization for diverticulitis

Signs/symptoms:• Asymptomatic disease.• Infectious complications• GIB.• Acute diverticulitis can present as mild intermittent pain or as

chronic severe unrelenting abdominal pain with Systemic symptoms of fever &change in bowel habits are common.

• Constipation 50% of patients & diarrhea in 25-35%.• Other symptoms include nausea, vomiting, urinary symptoms. • In cases of overt peritonitis, abdo exam may be notable for rigidity,

rebound tenderness,guarding. • Lab testing often reveals leukocytosis & elevated inflammatory

markers.

Diagnosis:• Can be diagnosed clinically with classic presenting symptoms or

more frequently with radiologically or colonoscopy.

Diagnosis:Radiology• Classically, barium enema was used for the diagnosis of DD.• CT has become the standard for diagnosing DD.• Both CT abdomen / pelvis & CT colonography are effective in

diagnosing the disease, extent of disease& complications.• The sensitivity for acute diverticulitis is 94%, with a specifcity of

99%.• On CT Buckley or Hinchey classification system can be used to

assess the severity of diverticulitis.

Diagnosis: colonoscopy

• Colonoscopy is the main diagnostic tool for diagnosing diverticular disease.

• Asymptomatic DD is a frequent incidental finding on screening colonoscopy.

• Colonoscopy is not used in acute diverticulitis, concerned for possible perforation related to air insufflation.

• Diverticulitis can be identified on colonoscopy &seen in up to 2% of screening colonoscopy,but cannot identify disease complications such as abscess.

DD of diverticulitis:

• IBD.• Ischemic colitis: BPR• AA.• Infectious colitis.

Diverticulitis management: uncomplicated

• Antibiotics & bowel rest. • When there are no signs of systemic toxicity, patients can be safely

treated with oral antibiotics in an outpatient setting but with more moderate – severe disease should be hospitalized / treated with IV antibiotics &bowel rest.

• It is associated with few complications & rarely necessitates emergent surgery.

• Antibiotics shouldcover aerobic &anaerobic gram-negative bacteria. • Antibiotics may not even be necessary in cases of mild-moderate

uncomplicated disease. • AGA recommend that antibiotics should be used selectively with

uncomplicated diverticulitis.

Diverticulitis management:complicated

• Present with a phlegmon, abscess, peritonitis, fistula, or obstruction.

• Typically, the infection spreads locally involving structures adjacent to the area of inflammation (eg, bladder / hip joint) or via the portal circulation to hepatic abscesses.

• In complicated disease evident on CT, patients should be hospitalized, IV antibiotics, bowel rest&surgical consult.

• Diverticular abscess may develop in up to 16% of patients with acute diverticulitis.

• With abscess, definitive therapy with surgery or PC drainage is often necessary.

• The diverting ileostomy was associated with reduced rates of complications, operating time, hospital stay&lower in-hospital costs

Diverticulitis management:complicated

• Perforation / peritonitis with rupture into the peritoneal cavity is rare, only 1- 2% with mortality20%.

• Fistulous tracts form in up to 12% of patients with diverticulitis to adjacent organs, most often involving the bladder followed by vaginal, cutaneous&enterocolic.

• The readmission&need for emergent surgery after the nonoperative management of diverticulitis is low,but with complicated disease there is high risk of readmission &need for emergent surgery.

Diverticulitis mngmnt:Segmental colitis

• Infrequently seen chronic colitis involving areas of diverticula.• Often be mistaken for IBD, especially Crohn. • Diverticula will have erythematous/friable mucosa with exudate&

surrounding mucosa around diverticula may also be involved. • Aphthous ulcers are not usually seen,but common in Crohn’s. • On histology: chronic colitis without granuloma&typically the

rectum should be spared of as diverticula do not involve the rectum • Patients who have persistent symptoms of abdominal pain, rectal

bleeding, or diarrhea may be treated similarly to those with IBD, & often 5-ASA,If symptoms persist, limited surgical resection , but surgery should be done cautiously ? SCAD may be a precursor of IBD&surgery is not curative in CD.

Psychosomatic omplications:

• Impaired QOL.• Psychological reactions.• IBS?.

Follow up colonoscopy:

• Current societal guidelines recommend colonoscopy 4 - 8 weeks after an episode of diverticulitis.

• In the first year after after admission for DD, there is an increased risk of CRC.

Abstract:

• DD;common associated with variable presentations. • They are structural changes within colonic wall forming pockets

from herniation of colonic mucosa / submucosa through defects in the circular muscle layers within, at the sites of penetrating BVs.

• DD is very common, most common incidentally finding on Cscopyy. • RFs: obesity, smoking, NSAIDs, corticosteroids,opiates. • Recent studies ? its role in development &protection.• Most asymptomatic, but subsets may develop nonspecific abd pain

(isolated or recurrent), diverticulitis, or div-associated seg colitis• Recent evidence indicates that in mild –moderate uncomplicated

diverticulitis, antibiotics may not be necessary,but in more complicated diverticulitis, IV Abs & surgery may be necessary.

• Increasing fiber ,5-ASA may prevent future attacks of diverticulitis, but antibiotics, probiotics, surgery may not.